# NTSB CEN11FA253: Piper PA46-350P, N619VH, Monroe, MI, March 29, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 29, 2011, 16:04 local (20:04 UTC) - Place: Monroe, MI - Coordinates: 41.939998, -83.434722 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.9400&lon=-83.4347&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report November 26, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Piper Aircraft, Inc., Lycoming, Federal Aviation Administration - NTSB case key (mKey): 78711 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11FA253 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78711/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78711 - Page: https://openairdocs.org/ntsb/CEN11FA253 ## Probable cause The pilot's demonstration of poor judgment by attempting a high-speed pass several feet above the runway and his subsequent failure to maintain clearance from the runway. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA 46-350P, 8 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7104620), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Piper PA 46-350P, 6 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7104620), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Piper PA 46-350P, 15 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7104620), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Propeller system: propeller blade section](https://openairdocs.org/ntsb-findings/01046111): Aircraft › Aircraft propeller/rotor · Damaged/degraded (probable cause); cases with it: [Piper PA 46-350P, 1 case](https://openairdocs.org/ntsb-findings/01046111/cases.md?model=7104620), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/01046111/cases.md) - [Aircraft capability: climb capability](https://openairdocs.org/ntsb-findings/01061010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA 46-350P, 1 case](https://openairdocs.org/ntsb-findings/01061010/cases.md?model=7104620), [All aircraft, 183 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md) - [Aircraft capability: cG/weight distribution](https://openairdocs.org/ntsb-findings/01061040): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation; cases with it: [Piper PA 46-350P, 3 cases](https://openairdocs.org/ntsb-findings/01061040/cases.md?model=7104620), [All aircraft, 66 cases](https://openairdocs.org/ntsb-findings/01061040/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02010000): Personnel issues › Physical · Pilot; cases with it: [Piper PA 46-350P, 1 case](https://openairdocs.org/ntsb-findings/02010000/cases.md?model=7104620), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/02010000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA 46-350P, 40 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7104620), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Maneuvering-low-alt flying: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=7104620), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Maneuvering-low-alt flying: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA 46-350P, 11 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7104620), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA 46-350P, 23 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7104620), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA 46-350P, 40 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7104620), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Piper PA 46-350P, 3 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=7104620), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## Analysis **This report was modified on 6/10/13. Please see the docket for this accident to view the original report.** While flying an approach, the pilot attempted to contact one of his flight instructors. A witness reported and radar data showed the airplane approaching the runway at a higher-than-normal speed. As the airplane leveled low over the runway, the propeller began striking the runway surface. The damage from repetitive propeller strikes resulted in a loss of the thrust and airspeed necessary for flight. The airplane impacted the ground and subsequently caught fire. The postaccident examination of the wreckage confirmed that the airplane was configured with the landing gear and flaps retracted. No mechanical anomalies were observed that would have precluded normal operation of the airplane. Weight and balance estimates of the airplane indicated that the pilot was operating the airplane outside of its certified weight and center of gravity limits. Forensic toxicology performed on the pilot showed the presence of Hydrocodone and Dihydrocodeine, indicative of the pilot using disqualifying sedating cough or pain medications. These medications can impair performance in high workload environments. The level of medication found in the pilot’s blood at the time of the accident could not be determined. Additionally, Nortriptyline was detected in the pilot’s tissues. While the medications could have had degrading effects on the pilot’s performance, the investigation was not able to determine what role they may have played in the accident sequence. ## Factual narrative HISTORY OF FLIGHT On March 29, 2011, about 1604 eastern daylight time, a Piper PA46-350P, N619VH, impacted a field southeast of the departure end of runway 21 at Custer Airport (TTF), Monroe, Michigan. The certificated private pilot and two passengers were fatally injured. The airplane sustained substantial damage to the fuselage. The airplane was registered to Triple F Aviation LLC and was operated by the pilot under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed and a flight plan had been filed for the flight that departed from Bedford County Airport, Bedford, Pennsylvania, about 1426, and was en route to TTF. A witness reported that the airplane was unusually low and still flying at a high rate of speed with its landing gear retracted when it flew over Stewart Road. The airplane continued at a high rate of speed as it crossed over the trees adjacent to runway 21. Radar data indicated that the airplane's ground speed was 132 knots, at an altitude of 800 feet, and a heading of 207 degrees when it was about 0.5 miles from runway 21 (4,997 feet by 100 feet, grooved asphalt). A second witness said that the pilot attempted to contact a flight instructor who had previously flown with the pilot while the airplane was approaching TTF. The flight instructor was employed at a TTF fixed base operator and was also a Federal Aviation Administration (FAA) Safety Team (FAAST) Representative. Another witness reported that he saw the airplane in a turn with "little speed." The airplane then "just dropped." The left wing and nose hit the ground simultaneously. PERSONNEL INFORMATION The pilot, age 58, held a private pilot with an instrument rating. He was issued a third class airman medical certificate on December 2, 2009, with the following limitation: "must have available glasses for near vision." At the time of his medical certificate application, he reported a total flight time of 1,600 hours. His last flight review was April 6, 2010. The pilot had no FAA record of previous incidents, accidents, or enforcement actions. AIRCRAFT INFORMATION The 2006 Piper PA46-350P airplane, serial number 4636402, was powered by a Lycoming TIO-540-AE2A engine, serial number L-12591-61A. The airplane was equipped with a Hartzell HC-I13YR-1RF, serial number HK1264B, 3-blade, composite propeller. The airplane had the following maximum weights and center of gravity (CG) range: Ramp weight: 4,358 lbs Takeoff weight: 4,340 lbs Landing weight: 4,123 lbs CG at maximum ramp weight: 144.14 - 147.1 inches According to FAA airman records, the pilot reported a weight of 175 lbs. Department of Motor Vehicle records list the right front passenger weight as 183 lbs and the rear-seat passenger as 207 lbs. The Piper PA46-350P has a usable main fuel tank capacity of 120 gallons. Prior to departure from TTF, the airplane main fuel tanks were topped off and 5 gallons of fuel was added to each wing tip tank. According to Piper Aircraft estimates of airplane weight andbalance, the airplane total weight was 4,474 lbs and with a CG of 142.24 inches when it originated from TTF. With a fuel consumption of 31 gallons, the airplane total weight was 4,288 lbs and a CG of 141.89 inches. These CGs were based upon the rear-seat passenger being seated in the aft most seat. According to a weight and balance form for the airplane dated January 5, 2007, the airplane had a useful load of 1,168.96 lbs. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was conducted by the Office of the Wayne County Medical Examiner, Detroit, Michigan, on March 30, 2011. The cause of death was cited as: '...multiple injuries sustained as a pilot of plane that crashed." The FAA Final Forensic Toxicology Fatal Accident Report reported the following for substances tested: Volatiles - No ethanol detected in urine Atenolol detected in Liver - Atenolol detected in Kidney - 0.082 (ug/mL, ug/g) Dihydrocodeine detected in Urine - 0.216 (ug/ml, ug/g) Hydrocodone detected in Urine - Nortriptyline detected in Liver - Nortriptyline detected in Kidney WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located at global positioning system coordinates and elevation: 41 degrees 55.663 minutes North, 083 degrees 26.041 minutes West or approximately 1,800 feet southeast of the departure end of runway 21. The tail to nose wreckage heading was about 220 degrees. The wreckage exhibited impact and fire damage to the fuselage. Examination of the main wreckage revealed that the landing gear was in the retracted position and the flaps were in the retracted position. The propeller was attached to the hub but was separated at the propeller blade roots. The separation features were consistent with a propeller strike. Examination of runway 21 noted 37 marks within the runway surface consistent with propeller slash marks that began about 2,000 feet down runway 21. Material consistent with the airplane propeller was located in the area of the slash marks. Sixteen slash marks beginning about 2,000 feet down the runway were separated beginning with 21 inches and with a range of about 21 - 29.5 inches. The remainder of the slash mark spacing ranged from about 29.5 to 40 inches. Examination of the wreckage revealed no mechanical anomalies that would have precluded normal operation. ## Aircraft - Registration: [N619VH](https://openairdocs.org/deregistered/N619VH-2018-01-25), registration cancelled 2018-01-25, S/N 4636402, built 2006 (OpenAirDocs) - Reported make and model: PIPER PA46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104619) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AE2A](https://openairdocs.org/engine/lycoming-tio-540-ae2a) (registry code 41999, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4636402 - Airframe hours: 851.2 - Engines: Lycoming TIO-540-AE2A 350 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Part 91 - Operator: Pilot - Registered owner: Triple F Aviation LLC - Last inspection: Annual, February 7, 2011 - Departed: HMZ, Bedford, PA - Destination: TTF, Monroe, MI - Flight plan: IFR - Airport: TTF, Custer Airport, runway 21, 4,997 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review April 6, 2010; seat: left; toxicology performed; flight hours: 1,600 total ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 43 °F, dew point 18 °F - Altimeter: 30.23 inHg - Observed at: TTF ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20110329010319A](https://openairdocs.org/incident/20110329010319A), Mar 29, 2011: Piper Aircraft Inc PA 46-350P, Monroe, MI, Destroyed, 3 fatal. On March 29th at about 1604 EDT N619VH, a Piper PA46-350P impacted a field southeast of the departure runway 21 of Custer Airport (kttf). The aircraft was on… ## Docket (14 files) The files NTSB released with the investigation on July 31, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78711. 3.1 MB in all. - Mobile Phone Device - Specialist's Factual Report (item 1, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359028&FileExtension=.PDF&FileName=Mobile%20Phone%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Witness Statements (item 2, .PDF, 776 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371238&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Radar Data (item 3, .PDF, 849 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370459&FileExtension=.PDF&FileName=Radar%20Data-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams - Monroe City Police Department (item 4, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370944&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams%20-%20Monroe%20City%20Police%20Department-Master.PDF - Measurement of Marks on Runway 21 (item 5, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370947&FileExtension=.PDF&FileName=Measurement%20of%20Marks%20on%20Runway%2021-Master.PDF - Fuel Receipt (item 6, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371188&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Weight and Balance Form for N619VH (item 7, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371221&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Form%20for%20N619VH-Redacted.PDF - Weight and Balance Estimate - Piper Aircraft (item 8, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371185&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Estimate%20-%20Piper%20Aircraft-Master.PDF - Toxicological Report (item 9, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370460&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370967&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371259&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Original Brief Report (item 12, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394709&FileExtension=.PDF&FileName=Original%20Brief%20Report%0D%0A-Master.PDF - Incoming Petition for Reconsideration (item 13, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394710&FileExtension=.PDF&FileName=Incoming%20Petition%20for%20Reconsideration-Master.PDF - Revised Narrative and PC (item 14, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394712&FileExtension=.PDF&FileName=Revised%20Narrative%20and%20PC-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.